As people around the world come to acknowledge that gender is something defined along a spectrum rather than a binary concept, the necessity of a “gender dysphoria” diagnosis needs to be revisited.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is used by mental health practitioners around the world, defines gender dysphoria as psychological distress that results from an incongruence between the gender an individual was assigned at birth and one’s gender identity.
As an advocate, provider, and CEO at a gender-affirming health care center, I have a problem with that term, as do a growing number of people in the transgender and gender-diverse communities, especially those who have early access to affirming support structures and care. Dysphoria is not the experience of all trans people. With appropriate care and affirmation, in fact, many may go on to experience “gender euphoria” because they are not stigmatized and seen as “other” but instead are welcomed and personal experience is not questioned. Under this model, gender diversity is seen as part of the human experience.
The U.S. is experiencing increases in gender diversity, greater acceptance of gender diversity, and majority opposition to anti-transgender laws. In short, more trans people are finding acceptance and culturally competent health care which allows them to thrive.
To be sure, many trans people do experience gender dysphoria, which is to be expected in a community that is not monolithic. But its practical application is problematic. The “diagnosis” of gender dysphoria has become a requirement for receiving medically necessary gender-affirming care for patients, even though the diagnosis doesn’t apply to all trans people. As with all forms of health care, a diagnosis is required for an insurer to pay for medically necessary care. Gender-affirming care is medically necessary, and pigeonholing it into one form of experience is not the lived reality of all trans individuals.
Some have called for the American Psychiatric Association, which created and is updating the DSM-5, to remove this diagnosis entirely, as it conflates a social identity with a mental disorder and propagates stigma. Others have argued that the diagnosis is necessary to cover medically necessary treatment — and it does guarantee that certain populations, such as incarcerated people or members of the armed forces, have access to care deemed medically necessary under the law and accepted by major medical organizations such as the American Medical Association.
My colleagues and I at Transhealth Northampton, a groundbreaking trans-led gender-affirming health care center, see patients who report experiencing gender dysphoria. Eliminating this diagnosis would invalidate their experiences. On the other hand, not all patients seeking affirmation receive a gender dysphoria diagnosis. And many patients report euphoria — or something akin to normalcy — when their gender identity is embraced and affirmed, whether they are receiving affirming health care services or not. Affirmation is the process of being seen by others and oneself, and being accepted for who one is and being able to live one’s life without others saying their trans experience is wrong. This affirmation may require clinical intervention, or it may not. In the end, it’s up to the person.
Instead of eliminating the diagnosis of gender dysphoria, insurers could solve the problem by simply not requiring that as a condition for accessing gender-affirming care. When health care providers require a specific diagnosis, we also require individuals to present a certain way and tell a specific story (which can be clinically inaccurate), and we limit access to care overall.
Medical necessity is defined by accepted standards of medicine and determines whether a certain treatment should be reimbursed by insurers. Insurers use more than diagnoses to determine medical necessity. Some treatments are deemed necessary based on your age or gender, such as a colonoscopy or mammography.
To better serve all patients, insurers should decide medical necessity not by a diagnosis but by reported identity. Expanding access to gender-affirming care will save even more lives.
Providing gender-affirming care to trans people because they are trans, not because they have a specious diagnosis, would have four important outcomes: One would be to help reduce stigma. The second would be to stop conflating mental illness with an identity. This approach would remove the requirement of having a mental health clinician assess an individual for a mental “disorder” which, given the paucity of clinically competent and gender-affirming mental health clinicians in the U.S., would improve access to gender-affirming care, a third important outcome. Finally, abandoning the dysphoria diagnosis for insurance reimbursement would also recognize the reality of the trans experience: There is no single way to be trans, just as there is no one way to transition or access medically necessary care.
Some may worry that removing this requirement would put vulnerable trans people, such as those who are incarcerated, at risk of losing access to care by making it seem as if this care is not medically necessary. Instead, having insurers no longer require a diagnosis of gender dysphoria in order to cover gender-affirming care, moves the country’s system closer to a path of health promotion, one goes beyond treating pathology and fosters wellness.
Being trans is not a disorder. It is an identity, and it is time for clinicians and insurers to treat provide care to diverse trans communities to act accordingly. Demedicalizing identity acknowledges our shared humanity and the importance of good health care for all people.
Dallas Ducar is a nurse practitioner and the founding CEO of Transhealth Northampton.
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